C. Lanchon

High Grade Blunt Renal Trauma: Predictors of Surgery and Long-Term Outcomes of Conservative Management. A Prospective Single Center Study

PURPOSEnThe management of major renal trauma has shifted in the last decade in favor of a nonoperative approach. Our level 1 trauma center promotes this approach with the objective of renal function preservation. However, certain situations still require surgery. In this study we analyze predictors of surgery and long-term outcomes after conservative management.nnnMATERIALS AND METHODSnFrom January 2004 to March 2015 we prospectively collected data from all patients admitted to our institution for high grade blunt renal trauma (grades IV and V). Nonoperative management was considered successful when patients did not undergo surgical exploration, regardless of angioembolization or endoscopic treatment.nnnRESULTSnOf 306 patients with renal trauma 151 presented with major injuries, including 124 grade IV and 27 grade V. Nonoperative management was successful in 110 (89%) cases of grade IV and 14 (52%) cases of grade V lesions. Deceleration mechanism (p=0.03), associated lesions (p=0.001), percentage of devitalized parenchyma (p=0.012), angioembolization (p <0.001), hemodynamic instability (p <0.001) and low hemoglobin (p=0.001) were more frequent in patients treated surgically. On multivariate analysis grade (OR 7.36, p=0.01) and hemodynamic instability (OR 4.18, p=0.04) were the only independent predictors of surgical treatment. Long-term followup of preserved kidneys revealed a remaining 40% and 0% relative renal function after grade IV and V injuries, respectively. Only devascularized parenchyma greater than 25% predicted the decline of long-term renal function.nnnCONCLUSIONSnNonoperative management can and should be performed safely in cases of grade IV injuries whenever possible, with valuable long-term renal function. It can also be initiated in grade V cases. However, surgeons should consider nephrectomy with the onset of any suspicious symptoms.

Partial nephrectomy versus ablative therapy for the treatment of renal tumors in an imperative setting

PurposeTo compare partial nephrectomy (PN) and percutaneous ablative therapy (AT) for renal tumor in imperative indication of nephron-sparing technique (NST).Materials and methodsBetween 2000 and 2015, 284 consecutive patients with a kidney tumor in an imperative indication of NST were retrospectively included in a multicenter study. PN [open (nxa0=xa0146), laparoscopic (nxa0=xa09), or robotic approach (nxa0=xa017)] and AT [radiofrequency ablation (nxa0=xa0104) or cryoablation (nxa0=xa08)] were performed for solitary kidney (nxa0=xa0146), bilateral tumor (nxa0=xa078), or chronic kidney disease (CKD) (nxa0=xa060).Results Patients in the PN group had larger tumors and a higher RENAL score. There were no differences between the two groups with respect to age, reasons for imperative indication, and preoperative eGFR. Patients in the AT group had a higher ASA and CCI. PN had worse outcomes than AT in terms of transfusion rate, length of stay, and complication rate. Local radiological recurrence-free survival was better for PN, but metastatic recurrence was similar. Percentage of eGFR decrease was similar in the two groups. Temporary or permanent dialysis was not significantly different. On multivariate analysis, PN and AT had a similar eGFR change when adjusted for tumor complexity, reason of imperative indication and CCI.ConclusionIn imperative indication of nephron-sparing treatment for a kidney tumor, either PN or AT can be proposed. PN offers the ability to manage larger and more complex tumors while providing a better local control and a similar renal function loss.

First Clinical Experience in Urologic Surgery with a Novel Robotic Lightweight Laparoscope Holder

PURPOSEnTo report the feasibility and the safety of a surgeon-controlled robotic endoscope holder in laparoscopic surgery.nnnPATIENTS AND METHODSnFrom March 2010 to September 2010, 20 patients were enrolled prospectively to undergo a laparoscopic procedure using an innovative robotic endoscope holder. Two surgeons performed six adrenalectomies, four sacrocolpopexies, five pyeloplasties, four radical prostatectomies, and one radical nephrectomy. Demographic data, overall setup time, operative time, number of assistants needed were reviewed. Surgeon satisfaction regarding the ergonomics was assessed using a 10-point scale. Postoperative clinical outcomes were reviewed at day 1 and 1 month postoperatively.nnnRESULTSnThe per-protocol analysis was performed on 17 patients for whom the robot was effectively used for surgery. Median age was 63 years; 10 (59%) patients were female. Median body mass index was 26.8. Surgical procedures were completed with the robot in 12 (71%) cases. Median number of surgical assistant was 0. Overall setup time with the robot was 19 minutes; operative time was 130 minutes during which the robot was used 71% of the time. Mean hospital stay was 6.94 ± 2.3 days. Median score regarding the easiness of use was 7. Median pain level was 1.5/10 at day 1 and 0 at 1 month postoperatively. Open conversion was needed in one (6%) case, and four minor complications occurred in two (12%) patients.nnnCONCLUSIONnThis use of this novel robotic laparoscope holder is safe, feasible, and provides good comfort to the surgeon.

Augmented Reality Using Transurethral Ultrasound for Laparoscopic Radical Prostatectomy: Preclinical Evaluation

PURPOSEnTo guide the surgeon during laparoscopic or robot-assisted radical prostatectomy an innovative laparoscopic/ultrasound fusion platform was developed using a motorized 3-dimensional transurethral ultrasound probe. We present what is to our knowledge the first preclinical evaluation of 3-dimensional prostate visualization using transurethral ultrasound and the preliminary results of this new augmented reality.nnnMATERIALS AND METHODSnThe transurethral probe and laparoscopic/ultrasound registration were tested on realistic prostate phantoms made of standard polyvinyl chloride. The quality of transurethral ultrasound images and the detection of passive markers placed on the prostate surface were evaluated on 2-dimensional dynamic views and 3-dimensional reconstructions. The feasibility, precision and reproducibility of laparoscopic/transurethral ultrasound registration was then determined using 4, 5, 6 and 7 markers to assess the optimal amount needed. The root mean square error was calculated for each registration and the median root mean square error and IQR were calculated according to the number of markers.nnnRESULTSnThe transurethral ultrasound probe was easy to manipulate and the prostatic capsule was well visualized in 2 and 3 dimensions. Passive markers could precisely be localized in the volume. Laparoscopic/transurethral ultrasound registration procedures were performed on 74 phantoms of various sizes and shapes. All were successful. The median root mean square error of 1.1 mm (IQR 0.8-1.4) was significantly associated with the number of landmarks (pxa0=xa00.001). The highest accuracy was achieved using 6 markers. However, prostate volume did not affect registration precision.nnnCONCLUSIONSnTransurethral ultrasound provided high quality prostate reconstruction and easy marker detection. Laparoscopic/ultrasound registration was successful with acceptable mm precision. Further investigations are necessary to achieve sub mm accuracy and assess feasibility in a human model.

The role for surgeryin high-risk prostate cancer

SummaryHigh-risk prostate cancer (PCa) refers to a very heterogeneous subgroup of disease. Recent series have shown very promising results of radical prostatectomy (RP)—alone or part as a multimodality approach—in patients with high-risk PCa, with satisfactory survival curves even though biochemical recurrence rate was high. Adjuvant treatment (radiotherapy (RT) alone or combined with androgen deprivation) was necessary in 20 to 54u2009% of patients, notably in cases with positive surgical margins. As for functional outcomes, urinary continence was preserved in about 92u2009% of cases and overall potency in 60u2009%. When comparing RP versus RT as primary treatment for high-risk PCa, a recent meta-analysis found surgery to be associated with an improved cancer-specific mortality compared with RT. In selected high-risk PCa young patients, surgery appears to be a valid option. Patients should however be informed of the possibility of adjuvant treatment, as part of a multimodal approach.ZusammenfassungHochrisiko-Prostatakrebs ist ein sehr heterogenes Krankheitsbild. Neueste Serien haben vielversprechende Ergebnisse der alleinigen chirurgischen Behandlung, beziehungsweise der Chirurgie als Teil eines multimodalen Ansatzes bei Patienten mit Hochrisiko-Prostatakarzinom gezeigt. Die Überlebenskurven waren zufriedenstellend, obwohl die biochemischen Rezidivraten erhöhte Werte zeigten. In 20–54u2009% war eine adjuvante Behandlung (Strahlentherapie allein oder in Kombination mit androgener Deprivation) notwendig, vor allem in Fällen mit positiven operativen Absetzrändern. Bei den funktionellen Ergebnissen wurde Harnkontinenz in etwa 92 % der Fälle beobachtet, die Erektion blieb in 60 % erhalten.~ Eine aktuelle Meta-Analyse konnte beim Vergleich der radikalen Prostatektomie gegenüber Strahlentherapie als Primärbehandlung für Hochrisiko-Prostatakarzinom-Patienten eine verbesserte krebsspezifische Mortalität im Vergleich zur alleinigen Strahlentherapie zeigen. In gut ausgewählten jungen Hochrisiko-Prostatakarzinom-Patienten ist ein chirurgischer Eingriff eine gute Option. Die Patienten sollten jedoch über die Möglichkeit der adjuvanten Behandlung als Teil eines multimodalen Ansatzes informiert werden.

Active Surveillance for Favorable Risk Prostate Cancer in African Caribbean Men: Results of a Prospective Study

Purpose: Active surveillance is a treatment option for favorable risk prostate cancer. However, data are missing on populations of African descent. We evaluated the safety and benefit of active surveillance in an African Caribbean cohort with favorable risk prostate cancer. Materials and Methods: Between 2005 and 2016, a single center, prospective cohort study was performed in Guadeloupe, French West Indies, including patients on active surveillance who had low risk prostate cancer (prostate specific antigen 10 ng/ml or less and Gleason score 6 or less) or favorable intermediate risk prostate cancer (prostate specific antigen 10 to 20 ng/ml, Gleason score 3 + 4 or less and life expectancy less than 10 years). Treatment was recommended in case of grade progression, increased tumor volume, prostate cancer doubling time less than 36 months or patient wish. Overall survival, disease specific survival and duration of active surveillance were calculated with the Kaplan‐Meier method. Multivariate analysis was performed using the Cox proportional hazards model to identify predictors of active surveillance termination. Results: A total of 234 patients with a median age of 64 years were enrolled in study. Median followup was 4 years (IQR 2.3–5.5). Overall survival at 30 months, 5 years and 10 years was 99.5%, 98.5% and 90.7%, respectively. Disease specific survival at 30 months, and 5 and 10 years was 100%. At 30 months, 5 years and 10 years 72.7%, 52.6% and 40.4% of patients, respectively, remained untreated and on active surveillance. Age (HR 0.96 per additional year, 95% CI 0.93–0.99) and prostate specific antigen density (HR 1.52 per additional 0.1 ng/ml, 95% CI 1.20–1.89) were found to be independent predictors of active surveillance termination. Conclusions: Active surveillance is safe and beneficial for highly selected African Caribbean patients. It seems to be feasible for patients at low risk and intermediate favorable risk. Prostate specific antigen density could help better select these patients.

Néphrectomie partielle droite pour tumeur complexe. Clampage suprasélectif aidé par le vert d’indocyanine

Objectifs Decrire la technique de clampage supra-selectif pour une nephrectomie partielle droite pour tumeur RENAL 10xa0xh. Methodes Identification prealable des pedicules vascularisant la zone tumorale. Dissection de l’artere renale. Reperage des arteres tumorales. Clampage enucleation tumorale. Resultats Ischemie supraselectivexa0: 12xa0minutes. Perte de fonction renalexa0: −1xa0%. CCC 5xa0cm, grade ISUPxa0III. Conclusion La technique de nephrectomie partielle par enucleation associee a un clampage supra-selectif permet une preservation renale optimale.

Technique de cystectomie–Bricker pour vessie neurologique totalement intra-corporelle cœlioscopique robot-assistée

Objectifs L’apport de la realisation totalement intra-corporelle d’une derivation trans-ileale selon Bricker pour vessie neurologique nous parait prometteuse en terme de qualite de geste chirurgical et de benefice postoperatoire pour le patient. Methodes Nous vous presentons ici le cas d’une patiente de 74xa0ans presentant une vessie neurologique instable handicapante secondaire (hernie discale C6-C7xa0avec moelle attachee). Apres une cystectomie totale classique robot-assistee, on isole une anse ileale de 15xa0cm sectionnee par des endo-GIA. L’anastomose ileo-ileale latero-laterale est realisee immediatement apres de maniere mecanique. L’anastomose uretero-ileale se fait manuellement selon Walace. Un orifice de trocard prealablement marque sert de point de sortie a l’anse ileale. Le montage a ete realise a gauche pour des soucis d’appareillage. Resultats L’intervention a dure 4xa0h. La gestion des sondes mono-J et leur passage trans-ileale puis trans-mesocolique doit etre protocolisee pour plus d’efficacite chirurgicale. Nous n’avons pas ete genes par des souillures fecales intra-abdominale. Les suites postoperatoires ont ete simples, permettant une sortie a j12xa0apres ablation des sondes ureterales. A 1xa0mois, la patiente est satisfaite de son montage et aucune complication n’est a deplorer. La creatinine est stable a 80xa0μmol/L. Conclusion Ce film decrit une technique reproductible de cystectomie–Bricker intra-corporelle. L’epargne cutanee et musculaire de la cœlioscopie robot-assistee a ete d’un veritable benefice chez cette patiente algique chronique.

Cystoprotatectomie totale robot-assistée avec curage pelvien étendu mono-bloc

Objectifs La cystoprostatectomie radicale avec neovessie ileale demeure un des traitements les plus lourds en chirurgie urologique. La voie mini-invasive robot-assistee, bien que techniquement complexe, pourrait permettre d’en alleger la morbidite. Nous presentons ici une cystoprostatectomie robot-assistee avec neovessie ileale entierement intracorporelle. Methodes Les ureteres sont reperes, suivis puis sectionnes. L’incision peritoneale est realisee du cul de sac de Douglas aux vaisseaux iliaques. Le curage pelvien est realise avec lymphostase par clips Hemolock. Les ailerons vesicaux sont sectionnes apres electrocoagulation au vessel-sealer . Le plexus veineux de Santorini est electrocoagule. Les recoupes uretrales et ureterales sont negatives en analyse extemporanee. La piece est mise en attente dans un sac d’extraction. Resultats Le patient avait 66xa0ans et presentait un carcinome in situ (CIS) de vessie resistant a la BCGtherapie. La duree de la cystoprostatectomie etait de 120xa0min, sans complications peroperatoires et des pertes sanguines a 200xa0cc. Les suites ont ete simples, avec reprise du transit a j4, ablation de la sonde vesicale j12xa0apres d’une opecification attestant d’une bonne etancheite de la neovessie. Les sondes JJ ont ete retirees a 1xa0mois L’histologie definitive retrouvait un pTisN0 (0/13) M0R0. Aucune recidive n’etait notee a 6xa0mois. Conclusion La cystoprostatectomie radicale robot-assistee avec remplacement ileal intracorporel est une technique faisable en un temps operatoire modere, permettant les memes resultats carcinologiques que la chirurgie ouverte, et des resultats fonctionnels satisfaisants.

Néovessie iléale robot-assistée intracorporelle selon Studer

Objectifs La cystoprostatectomie radicale avec neovessie ileale demeure un des traitements les plus lourds en chirurgie urologique. La voie mini-invasive robot-assistee, bien que techniquement complexe, pourrait permettre d’en alleger la morbidite. Nous presentons ici une cystoprostatectomie robot-assistee avec neovessie ileale entierement intracorporelle. Methodes Apres la cystoprostatectomie totale robotisee realisee en mono-bloc avec curages ganglionnaires par voie trans-peritoneale, les ureteres sont anastomoses selon la technique de Wallace. La derniere anse est prelevee, dont la section distale est realisee par une pince endoGIA 60. L’anastomose uretro-ileale est realisee a 24xa0cm du bout de l’anse par 2xa0hemi-surjets de Quill3/0. La section proximale est effectuee a 32xa0cm de l’anastomose. Le retablissement de continuite digestive latero-lateral est effectue en utilisant des endoGIA 60. L’anse est detubulisee et le plan posterieur suture par un surjet de Quill3/0. L’anastomose uretero-ileale est effectuee sur des sondes JJ. Le segment anterieur est modele et referme. Resultats Le patient avait 66xa0ans et presentait un carcinome in situ (CIS) de vessie resistant a le BCGtherapie. La duree de la derivation urinaire etait de 180xa0min, sans complications peroperatoires. Les suites ont ete simples, avec reprise du transit a j4, ablation de la sonde vesicale j12xa0apres d’une opecification attestant d’une bonne etancheite de la neovessie. Les sondes JJ ont ete retirees a 1xa0mois. Conclusion La cystoprostatectomie radicale robot-assistee avec remplacement ileal intracorporel est une technique faisable en un temps operatoire modere, permettant les memes resultats carcinologiques que la chirurgie ouverte, et des resultats fonctionnels satisfaisants.